White Water Rafting - a journey through difficult times - Dr Anand Chitnis, GP and Clinical Director NSC North Primary Care Network

The importance of Asking: Could it be Sepsis? - the Sepsis Trust

Sepsis is the body’s overreaction to an infection where, instead of fighting it, the immune system attacks the body’s own organs and tissues. Sepsis can occur from a small cut or insect bite to a chest infection or UTI. It’s more common than heart attacks and kills more people than bowel, breast and prostate cancer and road accidents combined. If it isn’t treated immediately as a medical emergency it can take someone’s life in under 24 hours.Sepsis is the body’s overreaction to an infection where, instead of fighting it, the immune system attacks the body’s own organs and tissues. Sepsis can occur from a small cut or insect bite to a chest infection or UTI. It’s more common than heart attacks and kills more people than bowel, breast and prostate cancer and road accidents combined. If it isn’t treated immediately as a medical emergency it can take someone’s life in under 24 hours.

The human and economic cost

Sepsis is an indiscriminate condition, claiming young and old lives alike and affecting the previously fit and healthy. Approximately eleven million deaths are caused by sepsis worldwide every year - many of those could be saved by increased public awareness, education for healthcare professionals and other basic care provisions.

Sepsis affects at least 245,000 people in the UK every year. 48,000 of these people lose their lives to the condition, and at least 40% of survivors suffer life-changing after-effects, be they physical, mental or emotional. Despite these statistics, awareness is still far too low.

Data from a study commissioned by the UK Sepsis Trust and carried out by the independent York Health Economics Consortium (YHEC) found that the cost of sepsis is likely to be £15.6 billion every year for the UK economy, rather than the £2.5 billion previously estimated. However, government intervention to improve access to healthcare and reliability of basic care could make a huge impact, saving thousands of lives and reducing the economic burden by as much as £2.8 billion (largely through minimising indirect costs incurred by lost productivity).

The road to recovery

Although awareness of sepsis is still far too low, lower still is the awareness of the potential aftermath. Sepsis is a life-threatening condition that can take a good deal of time for your body and mind to recover from. Some sepsis survivors experience a variety of physical, psychological and emotional problems while recovering. This is known as post-sepsis syndrome (PSS) and usually lasts between 6 and 18 months, sometimes longer. There is no specific treatment for PSS, but most people will get better with time. In the meantime, it’s a case of managing the individual problems and looking after yourself while you are recovering.

Some survivors find that their immune system is not as effective in the year following their sepsis. As a result, they get one infection after another, whether it’s coughs and colds, repeated water infections or a recurring wound infection.

Sepsis and COVID-19

The relationship between COVID-19 and sepsis is closer than first thought. Both trigger a disproportionate immune response, as well as sharing symptoms such as fever spikes, breathlessness and muscle pain. It’s likely that at least 25% of COVID-19 related deaths are caused by sepsis. As well as this, 20% of COVID-19 survivors are at risk of sepsis within 1 year – and sepsis survivors are at greater risk of developing COVID-19.  The recovery profile of patients surviving COVID-19 who have been in intensive care is similar to people who’ve had sepsis. Symptoms most commonly seen during recovery include (and are not limited to) PTSD, insomnia, anxiety, depression, chronic fatigue, short term memory loss, hair loss, swollen limbs, changes in vision and repeated infection. 

The UK Sepsis Trust set up the COVID-19 Recovery Response, extending their telephone and email support services to anyone hospitalised with the virus. UKST also launched a ‘Recovery after Critical Illness’ guide for survivors and their friends and family, and a ‘Returning to Work Following Critical Illness’ booklet for both survivors and employers, free to download via sepsistrust.org/covid-19-recovery-response/.

The Trust also created a campaign developed by our colleagues at 11-London entitled “Blurred Lines” to help disseminate messaging around the link between COVID-19 and sepsis. Through the generosity of an ongoing partnership with GroupM media investment company, the campaign was broadcast at no cost across online and print mainstream media (Daily Mail, Cosmopolitan, Metro News, Grazia etc) and on major billboards including in Birmingham City Centre and in London.

Hammersmith Roundabout, London

Improving care in the UK

In 2017, the UK Sepsis Trust launched clinical tools, such as Red Flag Sepsis and The Sepsis Six, alongside new guidelines from NICE regarding sepsis recognition and treatment. 

The Sepsis Six is a set of interventions which can be delivered by any junior healthcare professional working as part of a team – all it requires is a qualified prescriber and basic healthcare equipment. Executing these six steps in the first hour following a patient’s presentation with sepsis will double the patient’s chance of survival.

In 2019 the UK Sepsis Trust (UKST) announced findings from an APPG report on sepsis, revealing that the overwhelming majority of Trusts and hospitals are now using these UKST clinical tools. The report found that 80% of Trusts surveyed are also using UKST’s recognition pathway, Red Flag Sepsis and that nearly 100% of Trusts are using The UK Sepsis Trust’s treatment pathway, the Sepsis Six, both of which support NHS implementation guidance. The FOI report called for commitment from all NHS organisations to adopt these tools, for better use of data interoperability to identify those most at risk and, lastly, for a far-reaching public awareness campaign, endorsed by the Secretary of State, and produced by UKST.

The report showed that we’ve made great strides in the right direction when it comes to caring for those with sepsis, but it also shows that there is more to be done to improve sepsis care. Despite the fact that the overwhelming majority of Trusts are using our clinical tools, the problem of sepsis is more prevalent than ever. We must now urgently focus our attentions on further improving the identification and treatment of sepsis. Using interoperable data shared between hospitals and Trusts will enable healthcare professionals to identify more accurately those most at risk, and in most urgent need of care.

Improving care globally

In 2017 The World Health Organisation adopted a resolution on sepsis which makes the condition a global priority for policy makers and healthcare authorities.As part of the Global Sepsis Alliance (GSA) Executive Committee, Dr Ron Daniels BEM, CEO of UKST, helped to gather information from clinicians and families in over 70 countries, initiating a sepsis resolution which was unanimously recommended by the WHO’s Executive Board and adopted at the 70th World Health Assembly in Geneva.

The resolution meant that WHO Director-General Dr Margaret Chan drew more attention to the public health impact of sepsis, and it urged all 194 United Nations member states to develop action plans to help save lives and improve outcomes for survivors of sepsis in developed and developing countries.
The WHO has dedicated $4.6 million USD of its budget to implementing the resolution’s recommendations, which include the effective use of antimicrobials, the introduction of affordable vaccines, treating sepsis as an emergency, providing suitable services for survivors, communicating with patients and relatives using the term ‘sepsis’ to improve public awareness and engaging in advocacy efforts, including those centred around World Sepsis Day (13th September).

For more information please contact

UK Sepsis Trust, 2nd Floor, 36 Bennetts Hill Birmingham, B2 5SN

0800 389 6255

sepsistrust.org

Male sexual health - Krishna Sethia DM, FRCS

Although not usually the main topic of conversation around the dinner table or in a pub, problems with their sex lives are a source of major distress to large numbers of men. These difficulties are commonly related either to an inability to achieve an erection adequate for a satisfying sex life or to problems with ejaculation.

With regard to erectile dysfunction (ED) for many years it has been known that, in the Western world, by the age of 50 approximately 10% of men have completely lost their ability to achieve an erection and a further 20 - 30% have some significant difficulty. Whilst in years gone by men found this problem too embarrassing to discuss with their doctors, changing social practices together and the advent of better treatments has resulted in far less reticence. General practitioners are much more willing to discuss sexual problems and almost all UK urological departments are able to give specialist advice.

Achieving a satisfactory erection is a complex physiological event and difficulties may be broadly classified as due to organic or inorganic, i.e. psychological, factors. Particularly common organic causes of ED include diabetes, vascular or neurological diseases and major surgery especially operations performed in the pelvis. In addition there are a huge number of drugs that may have ED as a side-effect. Of note is the fact that although there is increasing interest in low testosterone as a potential cause of ED for most men there is little evidence that testosterone replacement improves erections. Some of the more obvious psychological causes of ED include stress, anxiety and depression.

One interesting condition that probably affects 1-2% of men and which can occur at any age is Peyronies disease. Francois de la Peyronie was physician to Louis XIII of France and he described the condition that bears his name in 1743. However it was undoubtedly it was present long before this. For example there are descriptions of the third century Roman emperor Theodosius waking with a bend in his penis that caused him to urinate into his face. The cause of Peyronies disease is unknown but it is probably caused by microscopic inflammation of tissue within the penis. This results in collagen, or scar tissue, being deposited which can have various consequences. First a lump may appear – whilst invariably alarming for the patient this lump is always benign. In the early stages it may be painful but again the pain will resolve within months. Of more concern is the fact that the scarring of one side of the penis results in men developing a bend in their erection. This can vary from very mild (causing no difficulty) to so severe that penetrative sex is physically impossible. In extreme cases the scarring can spread through the penis making erections themselves difficult to achieve.

The inflammation that gives rise to Peyronies disease burns itself out within 12-18 months. Unfortunately there are no treatments which speed this process up nor any which can lessen its effects on the penis. Doctors therefore have to advise patients to wait to see how the condition develops. If at the end of the day there is only a slight bend of the erection no further treatment is justified. However when the bend is severe surgery may be required to straighten the penis.

For most men there is little value in special investigations as to the cause of ED as the management follow well-defined pathways. Perhaps the major leap forward in treatment was the advent of Viagra (or sildenafil) in 1998 – the first tablet effective for the condition. Since then three other tablets have become available and approximately 70% of men benefit from them. Should they be ineffective there are other drugs which usually help and failing that it is possible to improve the situation surgically by implanting prostheses into the penis. It is fair to say that in this age it is almost always possible to restore a man’s erection if he is willing to try all of the available treatments.

Problems with ejaculation are increasingly recognised but, unfortunately, more difficult to manage. This is partly because the physiological processes which give rise to ejaculation are not well understood (they are completely different to those which cause erections). Therefore there are fewer drugs or other strategies which we know to be effective. Having said that it is often sensible to seek specialist advice as there may be ways of, if not curing, improving the man’s or the couple’s experience.

Content provided by Krishna Sethia DM, FRCS.